The Basics of Alcohol Screening, Brief Intervention and Referral to Treatment in the Emergency Department

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UC Irvine Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Title The Basics of Alcohol Screening, Brief Intervention and Referral to Treatment in the Emergency Department

Permalink https://escholarship.org/uc/item/2m13v8k9

Journal Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 8(3)

ISSN 1936-900X

Authors Vaca, Federico E. Winn, Diane

Publication Date 2007

Peer reviewed

eScholarship.org Powered by the California Digital Library University of California Sp e c i a l To p i c The Basics of Alcohol Screening, Brief Intervention and Referral to Treatment in the Emergency Department

Federico E. Vaca, MD, MPH Department of Emergency Medicine, University of California, Irvine Diane Winn, RN, MPH School of Medicine

Submission history: Submitted May 8, 2007; Accepted June 25, 2007 Reprints available through open access at www.westjem.org

Nearly eight million emergency department (ED) visits are attributed to alcohol every year in the United States. A substantial proportion is due to trauma. In 2005, 16,885 people were killed as a result of alcohol-related motor vehicle crashes. Patients with alcohol-use problems (AUPs) are not only more likely to drive after drinking but are also at greater risk for serious alcohol-related illness and injury. Emergency departments have an important and unique opportunity to identify these patients and intervene during the “teachable moment” of an ED visit. The American College of Emergency Physicians, Emergency Nurses Association, American College of Surgeons-Committee on Trauma, American Public Health Association, and the National Highway Traffic Safety Administration, have identified Alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) as a pivotal injury- and illness-prevention strategy to improve the health and well-being of ED patients. We provide a general overview of the basis and need for integrating SBIRT into EDs. Models of SBIRT, as well as benefits and challenges to its implementation, are also discussed. [WestJEM. 2007;8:88-92.]

Introduction as Alcohol Screening, Brief Intervention and Referral to In the United States (U.S.), someone is injured in an Treatment (SBIRT). alcohol-related motor vehicle crash every two minutes, and Although organized pre-hospital care and regionalization every 31 minutes an alcohol-related crash fatality occurs.1 of trauma centers have saved tens of thousands of lives over In 2005, these crash fatalities accounted for 39% of the the past 30 years, further progress through injury prevention 43,443 national traffic deaths.1 Between 1992 and 2000, U.S. will save the greatest number of lives in the shortest period of 12, 13 emergency departments had more than 860 million visits. time. SBIRT is one important prevention strategy that has Emergency Department (ED) visits attributable to alcohol great potential to make a significant impact in the health and during the same period averaged nearly 8 million annually well-being of ED patients. with an 18 % rise over nine years.2 Alcohol intoxication What Is SBIRT? remains a leading risk factor for injury.3-5 Similarly, alcohol In the last decade, SBIRT in EDs has gained significant is implicated as an independent risk factor in a multitude of momentum and acceptance. SBIRT allows medical and medical and psychiatric conditions (e.g. cancer, community- nursing professionals or specially trained personnel to quickly acquired pneumonia, cardiomyopathy, gastrointestinal, and effectively survey patients regarding their alcohol-use liver disease, pancreatitis, anxiety disorder, depression, habits (quantity and frequency) and categorize them as a schizophrenia)6-10. More recent studies have implicated non-drinker, drinker not at risk, drinker at risk or alcohol alcohol in other life-threatening events, such as intracerebral dependent. Survey tools commonly used in SBIRT have been hemorrhage in younger adults.11 validated in multiple settings worldwide. These questionnaires Alcohol’s impact on the public’s health is detrimental, gather information about a patient’s drinking frequency, habits and there is considerable need to mitigate alcohol-related and experiences. Today, the two survey tools most commonly illness and injury. Applying the public health model to the used in the ED are the CAGE questionnaire and the Alcohol readily identified burden results in preventive measures such Use Identification Test (AUDIT) (Table 1 and Figure 1).

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Table 1. CAGE Questionnaire identifies only alcohol-dependent subjects who likely need intervention beyond the scope of what can be provided during CAGE Questionnaire an ED visit. In contrast, the AUDIT is a 10-question survey (In the last 12 months) used by the World Health Organization that identifies a subject Have you ever felt you should Cut down on your drinking? “at risk” for harmful and hazardous events. The AUDIT Have people Annoyed you by criticizing your drinking? surveys three key domains (hazardous use, dependence Have you ever felt bad or Guilty about your drinking? symptoms, and harmful use), which yield a more complete Have you ever had a drink first thing in the morning to “steady profile of a person with an alcohol-use disorder. More your nerves” or get rid of a hangover (Eye Opener)? importantly, AUDIT identifies the individuals “at risk” for alcohol-use problems who may benefit the most from SBIRT. JA Ewing “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: Identification of “at risk” drinkers is only one part of the 1905-1907, 1984. SBIRT method. The intervention component of SBIRT is accomplished through a motivational interviewing technique better known as the brief negotiated interview (BNI). Utilizing The Alcohol Use Disorders Identification Test: Interview Version the BNI, introspective discussion and questioning of a patient Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask you some questions about your use of alcoholic beverages during this past year.” Explain what is leads to an eventual assessment of their willingness to modify meant by “alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard drinks”. Place the correct answer number in the box at the right. their alcohol consumption toward healthier limits (Figure 2 and 3). Finally, upon completion of the BNI, the patient’s 1. How often do you have a drinking obtaining 6. How often during the last year have you needed alcohol? a first drink in the morning to get yourself going after a heavy drinking session? new alcohol-use reduction goals and outpatient treatment and (0) Never [Skip to Qs 9-10] (0) Never follow-up plans are reviewed. (1) Monthly or less (1) Less than monthly (2) 2 to 4 times a month (2) Monthly (3) 2 to 3 times a week (3) Weekly (4) 4 or more times a week (4) Daily or almost daily Why SBIRT in the ED? Emergency departments remain the healthcare safety 2. How many drinks containing alcohol do you 7. How often during the last year have you had have on a typical day when you are drinking? a feeling of guilt or remorse after drinking? net for the nation. By default, millions of individuals seek (0) 1 or 2 (0) Never (1) 3 or 6 (1) Less than monthly “primary care” in the ED. SBIRT has the potential to reach (2) 5 or 6 (2) Monthly this vulnerable yet neglected population to identify drinking (3) 7, 8, or 9 (3) Weekly (4) 10 or more (4) Daily or almost daily patterns and habits that put them at significant risk for 3. How often do you have six or more drinks on 8. How often during the last year have you been alcohol-related illness and serious injury. Further, studies one occasion? unable to remember what happened the (0) Never night before because you had been drinking? repeatedly find that a substantial proportion of ED patients (1) Less than monthly (0) Never 14-16 (2) Monthly (1) Less than monthly have significant underlying alcohol problems. As a result, (3) Weekly (2) Monthly (4) Daily or almost daily (3) Weekly millions more will be caught in the cycle of recidivism for (4) Daily or almost daily alcohol-related disease and trauma.17, 18 4. How often during the last year have you 9. Have you or someone else been injured as a found that you were not able to stop drinking result of your drinking? According to the American College of Surgeons Committee once you had started? (0) No on Trauma (ACS-COT), as of 2006 all Level I and Level II (0) Never (2) Yes, but not in the last year (1) Less than monthly (4) Yes, during the last year trauma centers must be SBIRT-capable and integrate it into (2) Monthly (3) Weekly (4) Daily or almost daily their trauma service repertoire. Without this service, trauma centers place their verification status in jeopardy. While the 5. How often during the last year have you failed 10. Has a relative or friend or a doctor or another to do what was normally expected from you health worker been concerned about your ACS-COT makes the requirement for SBIRT clear for Level I because of drinking? drinking or suggested you cut down? (0) Never (0) No and II trauma centers in its publication, Resources for Optimal (1) Less than monthly (2) Yes, but not in the last year (2) Monthly (4) Yes, during the last year Care of the Injured Patient: 2006, it also recommends that all (3) Weekly 19 (4) Daily or almost daily trauma centers utilize SBIRT as part of routine trauma care. The ACS-COT, in collaboration with the Center for Disease Record total of specific items here If total is greater than recommended cut-off, consult User’s Manual. Control and Prevention, National Highway Traffic Safety Administration, and the Substance Abuse and Mental Health Service Administration, is holding national SBIRT training Figure 1. Alcohol Use Disorders Identification Test sessions for trauma care providers throughout the United Used with permission, World Health Organization, Department of States for the 2007 year.20 Finally, and most importantly, Mental Health and Substance Dependence, The Alcohol Use Disorders Identification Test, Guidelines for Use in Primary Care, Second Edition studies show that patients are amenable to participating 21 2001, page 17 in SBIRT and that SBIRT is efficacious in patients with alcohol-use problems.12, 22-29 In a review conducted by The CAGE questionnaire (four questions) is the simpler of D’Onofrio and Degutis, positive effects of SBIRT were found the two survey tools. However, the limited focus of CAGE in 32 of 39 clinical studies.24 SBIRT studies in EDs and trauma

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Figure 2. Users at Risk Figure 3. Negotiated Interview centers have reported reduction in alcohol consumption and additional effort or cost. repeat-injury hospitalizations as well as decreased drinking In our institution we have been successful in integrating and driving.12, 14, 23, 26, 30 a bilingual (English and Spanish) “roll-to-the-bedside” Computerized Alcohol Screening and Intervention (CASI) Models of SBIRT Administration kiosk prototype. We have found the average patient screening The most common models used to administer SBRIT to ED time with CASI to be less than five minutes. This kiosk is fully patients are emergency physician (EP)/nurse- directed SBIRT interactive through an audio and graphical interface. Through or administration through the use of specially trained health a touch-screen monitor and head phones, CASI engages the promotion/education paraprofessionals. These models are not patient in conversation, administers the AUDIT questionnaire, without their limitations. undertakes a brief negotiated interview, and prints a personal In busier EDs, it may be infeasible to have only emergency alcohol-reduction plan with referral to treatment information. physicians or nurses administer SBIRT. While time While the integration of a human-computer interaction model constraints in some ED settings are challenging, this should for SBIRT administration is feasible, more rigorous studies not completely preclude the integration of SBIRT into the using computerized SBIRT are needed to more completely ED. If resources allow, specially trained paraprofessionals assess its efficacy. Such efforts continue to be encouraged by can administer SBIRT. The added value of these personnel federal research funding agencies.35 can positively impact both customer satisfaction as well as health promotion activities.31 Another method for SBIRT Challenges to SBIRT Integration administration in a busy ED setting is that of using computer The availability of time to administer SBIRT in the ED is technology and human-computer interaction to accomplish arguably the most significant challenge. However, innovative SBIRT tasks and goals. The use of computers in the ED approaches to SBIRT delivery have helped to overcome for SBIRT and other health promotion activities has been this barrier in some EDs. Further, it should be noted that feasible and holds considerable promise.32-34 While several the majority of ED patients who will encounter SBIRT will variations in the method of computer use for SBIRT do exist, either be non-drinkers or drinkers found not to be at risk. they all focus on minimizing the physician time to administer This essentially removes 70–75% of those screened from the SBIRT; they also facilitate standardization and fidelity of brief negotiated interview. For subjects identified by SBIRT SBIRT delivery. Further, through relatively simple computer as “at risk drinkers” who undergo both the screening and programming and the use of software, computers offer greater brief negotiated interview, the aggregate time remains an facilitation of multi-lingual administration with little added average of 10 minutes. Further, with computerized SBIRT

Western Journal of Emergency Medicine 90 Volume VIII, n o . 3 : August 2007 Vaca et al Alcohol Screening, Brief Intervention and Referral the screening and brief intervention delivery is routinely less mandate, according to George Washington University Medical than 10 minutes for the “at risk” drinker. While for some the Center’s research group, Ensuring Solutions to Alcohol time expense to SBIRT may still be considered too much of a Problems, the 2007 federal legislative year may be the busiest “cost,” one only need compare the amount of time and vigor yet in repealing UPPL or Alcohol Exclusion Laws. Moreover, spent to screen patients for tetanus even though the average as of January 2007, current procedural terminology codes number of new tetanus cases per year in the U.S. is only 43.36 (CPT) have been approved to allow the U.S. Center for Contrast that to the number of annual alcohol-related crash Medicare and Medicaid Services to reimburse for alcohol fatalities of nearly 17,000, with nearly 8 million alcohol- and drug screening and brief intervention.38 While there are attributable ED visits every year. many more details to work out in billing and reimbursement Another challenge to SBIRT in the ED is the comfort for SBIRT, there is potential for a regular revenue stream level at which EPs and nurses can administer SBIRT to to counter the argument that ED personnel are too busy to patients. Some training and learning must take place before perform this critical public health intervention. the person-to-person SBIRT interaction becomes efficient and routine. Even though most acute care providers may be CONCLUSION comfortable asking a patient if they drink alcohol, a more in- Although the initial “cost” of implementing SBIRT in the depth discussion about alcohol-use patterns takes practice, ED may appear to be an additional burden, the savings are particularly as the healthcare professional conducts the brief great and include less recidivism and avoidance of alcohol- negotiated interview and motivates the patient to consider related medical illness, injury and fatality. Alcohol SBIRT healthier and safer alcohol use. In general, the skills to offers advantages to patient care, patient well-being and the become effective in delivering SBIRT in the ED are relatively public’s health. easy to acquire. Some helpful online resources can be found on internet web pages hosted by the American College of Emergency Physicians (http://www.acep.org/webportal/ Address for Correspondence: Federico Vaca, MD, MPH, PracticeResources/issues/pubhlth/alcscreen), the Substance University of California, Irvine Medical Center, Center for Trauma Abuse and Mental Health Administration (http://sbirt.samhsa. and Injury Prevention Research 101 The City Drive, Route 128-01 gov/ and http://sbirt.samhsa.gov/documents/SBIRT_guide_ Orange, CA, 92868 Email: [email protected] Sep07.pdf ) and the National Institute for Alcohol Abuse and Alcoholism (http://www.niaaa.nih.gov/Publications/ EducationTrainingMaterials/guide.htm). While physicians REFERENCES and nurses can become proficient at administering SBIRT, it 1. National Highway Traffic Safety Administration. Traffic Safety should be noted that the available resources and services for Facts 2005: Alcohol. 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